A. Limitation on x-ray submissions. In any claim for first, second, or third stage pneumoconiosis under § 65.2-504 of the Code of Virginia, the employer and the employee each shall be limited to submission of not more than three medical interpretations (readings) of x-ray evidence without regard to the number of x-rays. For good cause shown, additional interpretations may be received as evidence if deemed necessary by the commission.

B. Reading by Pulmonary Committee. Any party to a contested claim, or the parties upon agreement, may submit the x-ray evidence to the commission for interpretation by the Pulmonary Committee. If a party agrees to accept the x-ray reading of the Pulmonary Committee as the binding classification, the costs of evaluation shall be borne by the commission.

C. Appointment of Pulmonary Committee. The commission shall appoint a Pulmonary Committee to be composed of at least three qualified physicians certified as B readers under standards promulgated by the International Labour Organization (ILO).

D. Rule 10.4. Method for consensus classification of chest radiographs in pneumoconiosis cases.

1. Definitions. For purposes of this section, the following words and terms shall have the following meanings unless the context clearly indicates otherwise:

"Consensus Radiographic Report" means the standardized summary report prepared by the Pulmonary Committee chairman applying the consensus rules set forth in this Rule 10.4.

"Evidentiary record" means the complete record of medical evidence considered in the adjudicatory proceeding before the commission, including all independent B Reader classifications and the Consensus Radiographic Report.

"ILO Classification" means the current International Labour Organization Classification of Radiographs of the Pneumoconioses as specified in § 65.2-504 of the Code of Virginia.

"Independent B Reader classification" means a chest radiograph ILO classification performed without consultation, collaboration, or review of another reader's findings and without access to the worker's occupational or exposure history.

"Majority" means agreement by at least two of three Pulmonary Committee members.

"Median" means the middle profusion category when the three reported profusion scores are ordered from lowest to highest.

"True copy of the subject chest radiograph" means a true and correct copy of the original digital data in the digital imaging and communications in medicine (DICOM) format maintained by the facility where the subject chest radiograph of the claimant was obtained without any alteration, modification, or reformatting of that data.

2. Independent review requirement.

a. Each Pulmonary Committee member shall be a currently certified National Institute for Occupational Safety and Health (NIOSH) B Reader.

b. Each Pulmonary Committee member shall independently review a true copy of the subject chest radiographs consistent with the requirements set forth in 20 CFR 718.102 and 42 CFR 37.51 using medical diagnostic monitors.

c. No Pulmonary Committee member shall consult with, communicate with, or review the classification of another Pulmonary Committee member prior to submitting an individual reading.

d. Each reading shall be recorded using the ILO Classification and the ILO radiographic standard images, including all required elements.

e. Attorneys for the parties, and any parties acting pro se, shall certify to the commission that only true copies of the subject chest radiographs are being submitted for interpretation to the commission and to any B Reader privately retained by the parties.

3. Consensus determination. Following submission of all three independent B Reader classifications, the Pulmonary Committee chairman shall issue a Consensus Radiographic Report applying the following rules:

a. Type and shape of small opacities.

(1) Primary small opacity. The consensus primary small opacity (p, q, r, s, t, u) shall be determined as follows:

(a) If a majority exists for a small opacity, that classification shall be used; or

(b) If no majority exists, the consensus primary small opacity shall be the most frequently reported small opacity among the three readings.

(2) Secondary small opacity. The consensus secondary small opacity shall be determined as follows:

(a) If a majority exists for a secondary small opacity, that classification shall be used;

(b) If no majority exists, the secondary classification shall be the second-most frequently reported small opacity; or

(c) If no clear second-most frequently reported small opacity exists, the secondary classification shall be omitted.

(3) Split classifications. When readers report different opacities (e.g., q/p):

(a) The first-listed small opacity shall be treated as the primary small opacity, and the second-listed small opacity shall be treated as the secondary small opacity; and

(b) Frequency shall be calculated separately for primary and secondary small opacities.

b. Profusion and small opacities.

(1) Majority controls. If at least two of the three independent B Reader classifications report the same profusion category, that category shall constitute the consensus determination.

(2) Median applies if no majority. If no majority exists, the consensus profusion category shall be the median of the three reported profusion scores.

c. Large opacities.

(1) The presence and classification (Category A, B, or C) of large opacities shall be determined by majority.

(2) If at least two of the three independent B Reader classifications identify any Category A, B, or C large opacities, the Consensus Radiographic Report shall reflect third-stage pneumoconiosis in accordance with § 65.2-504 A 3 of the Code of Virginia and the pneumoconiosis table in 16VAC30-50-120.

d. Other abnormalities.

(1) Other radiographic abnormalities shall be reported on the Consensus Radiographic Report only where a majority of the independent B Readers identify the same abnormality.

(2) If any one of the three Pulmonary Committee members report in an independent classification that the worker should see a personal physician because of that reader's findings, § 4E of the Consensus Radiographic Report shall be marked in the affirmative, and the commission shall notify the claimant or the claimant's counsel.

4. Documentation and evidentiary record.

a. The Consensus Radiographic Report shall:

(1) Identify the consensus determinations reached under subdivision 3 of this subsection; and

(2) Document the application of majority and, where applicable, median rules.

b. All three independent B Reader classifications, in full and without alteration, shall be included in the evidentiary record and shall be provided to the parties together with the Consensus Radiographic Report.

5. Purpose and construction. This rule shall be construed to do the following:

a. Promote consistency, transparency, and medical reliability;

b. Preserve the contributions of individual ILO classifications; and

c. Provide a clear, consistent, and administrable framework for resolving differences in the ILO classification of radiographic images in pneumoconiosis cases.